P H S Indian Hospital Crow / Northern Cheyenne

“PROPER VENTILATION, LIGHTING, AND TEMPERATURE CFR(s): (5) There is proper ventilation, lighting, and temperature control in all pharmaceutical, patient care, and food preparation areas. This Standard is not met as evidenced by: 29047 Based on observations, interviews, and record review s, the hospital failed to maintain a comfortable environment for three (#1, #2, and #3) of three patients observed, by ensuring that discharge air temperatures (cold, conditioned air blowing out of vents, which when directed at a stationary patient, can cause significant discomfort) from the heating, ventilation, and air conditioning (HVAC) system did not cause patient discomfort. This failure had the potential to affect all patients admitted to the hospital, based on the design and location of the discharge air diffuser (a device installed at the opening of a vent that distributes discharge air) that directed cold air directly on patients. The hospital census was three. Findings include: 1. On 4/7/26 at 10:38 a.m., and 3:00 p.m., observations of Patients’ #1, #2, and #3 rooms (A221, A222, and A224), showed a diffuser located in the celling, over the patients’ beds, positioned slightly to the side (not directly above). In room A222 and A224, a linear slot diffuser (long, narrow HVAC air outlet with thin, elongated slots) forced air down on the patients who were lying or sitting in bed. All three patient rooms contained space heaters that were on and in use. On 4/7/26 at 3:02 p.m., during an interview, Patient #1 stated it was cold at night in the room, and it felt like the air conditioner was blowing cold air on the patient. On 4/7/26 at 3:45 p.m., Area Facilities Operator (Operator #3) was interviewed. Operator #3 stated the heating and cooling design of the patients’ rooms caused 54-to-60-degree discharge air to blow directly on the patients. “We get lots of complaints from patients who say, ‘I’m cold’.” Operator #3 explained that the design and location of the diffuser in rooms A221, A222, and A224, caused the cold air to blow directly down on the patients. The temperature of the discharge air was impacted by the room temperature, adding that the use of space heaters in the room further lowered the discharge air temperature. “It’s a bad design and unfortunately, we did that to our patients.” Review of the hospital’s temperature monitoring report titled, “Zone & Discharge,” showed that between 4/6/26 at approximately 5:00 p.m., and 4/8/26 at approximately 8 a.m., the discharge air temperature: - For room A221, ranged from 56 to 69 degrees. - For room A222, ranged from 56 to 67 degrees. - For room A224, ranged from 56 to 69 degrees.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 29047 Based on observations, interviews and record reviews, the hospital failed to prohibit the use of space heaters. Space heaters were found in use in three (Patient #1, #2, and #3) of three patients’ rooms (A221, A222, and A224). A total of seven space heaters were located in the hospital, and in use or available for use. This failure had the potential to affect all patients and staff, as the use of unapproved space heaters poses a significant fire and safety hazard. The hospital census was three. Findings include: 1. Review of the hospital’s procedure titled, “Electrical Safety Procedure CSU [Crow Service Unit]” dated 06/2022, showed the use of portable heating devices such as electric space heaters, were prohibited anywhere in the building. On 4/7/26 at 10:38 a.m., and 3:00 p.m., space heaters were observed in three (Patient #1, #2, and #3) of three occupied patient rooms on the inpatient care unit (rooms A221, A222 and A224). In room A222, the following, flammable items were found in close proximity to the space heater: - A helium balloon approximately six feet above; - Pieces of printer paper within 12 inches; - Birthday cards within 36 inches; - A plastic trash can liner within 36 inches; and - Bed linens within 30 inches. On 4/7/26 at 4:15 p.m., a space heater was observed underneath the security desk, located inside the front entrance of the hospital. On 4/7/26 at 3:15 p.m., an interview with Facilities Supervisor (Supervisor #1) was conducted. Supervisor #1 stated he did not know how many space heaters were in the hospital, was not monitoring where the heaters were located, and was unaware the space heaters were in use in patient care areas. On 4/7/26 at 4:00 p.m., an interview was conducted with Area Director of Quality (Director #2). Director #2 stated after reviewing the facility policy, space heaters were not permitted in the hospital, and therefore all space heaters in the hospital should be removed. On 4/7/26 at 4:00 p.m., an interview was conducted with Director #2, who stated that six space heaters were located inside the hospital (this did not include the space heater located underneath the security desk, located inside the front entrance of the hospital).”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 29047 Based on interview and record review, the hospital failed to implement measures to reduce the risk of bed bug infestation, when relevant education was not provided to all staff, after two patients (Patient #1 and #2) with multiple presentations to the hospital, were identified with visible bed bugs. See tag C-1225 for more details.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (1) The governing body, or responsible individual, must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 29047 Based on interview and record review, the hospital failed to implement measures to reduce the risk of bed bug infestation, when relevant education was not provided to all staff, after two patients (Patient #1 and #2) with multiple presentations to the hospital, were identified with visible bed bugs. Findings included: Review of the hospital’s policy titled, “24.23 Bed Bug Control” dated 02/2018, showed that: - Early detection and prompt professional treatment is the most time and cost-effective solution for bed bugs. - Will “provide ‘all staff’ provided” with information on prevention, collection of specimens and control of parasites. - Vigilance in implementing prevention and control measures is critical for successfully controlling/eliminating parasites. - The policy was revised 12/2025. During an interview on 12/16/25 at 8:40 AM, multiple hospital administrators confirmed a community-wide bed bug outbreak, with increasing amounts of patients with bed bugs coming into the Emergency Department (ED). The administrators stated that Patient #1, who came to the hospital daily for care, had been identified by a laboratory staff member (Staff A) as having visible bed bugs on her body. Review of the visit history for Patient #1 showed the patient presented to the hospital 36 times between 08/19/25 and 12/11/25. Review of a hospital event report dated 08/27/25, showed that Staff A, Laboratory draw room Technician, identified bed bugs on Patient #1 on 08/19/25. Staff A documented that when she assisted the patient with a transfer, bed bugs fell from the patient, and scattered on the laboratory draw room and bathroom floor. The patient’s healthcare provider, the hospital’s Quality Management, and Staff A’s supervisor were notified of the event. On 10/06/25 (almost six weeks later), the event report was referred to the hospital’s Patient Safety Officer/Risk Manager, and Infection Control (Infection Preventionist). Review of a hospital event report dated 08/27/25, showed that Staff A documented that Patient #1 returned to the hospital, and both the patient and the patient’s husband were visually covered with bed bugs. There were bed bugs found “all over” the floor in the laboratory waiting room, and some were found on the waiting room chairs. Staff A’s supervisor, Facility Management, and Infection Control were notified. Review of a hospital event report dated 09/23/25, showed that on 09/21/25, Patient #1 presented to the inpatient unit for an infusion, and was noted to have bed bugs. Review of an Occupational Safety and Health Administration (OSHA) letter dated 09/30/25, showed the hospital was notified of allegations that employees were exposed to health hazards due to a bed bug infestation within the hospital. A response submitted by the hospital on 10/07/25 showed that the hospital identified a patient (Patient #1) with bed bugs on the inpatient unit on 09/21/25 (first report of bed bugs per event report was 08/19/25, over four weeks earlier than stated), and documented steps the hospital had taken to minimize the risk of transmission, including education that consisted of watching a video. The education was not initiated until 10/02/25 (over six weeks after the initial report of bed bugs), and did not include laboratory, pharmacy, Public Health Nursing (PHN), or outpatient clinic staff. Review of a hospital event report dated 10/24/25, showed that Patient #2, spouse of Patient #1, was in the ED and was observed with bed bugs crawling on his clothing. Review of the visit history for Patient #2 showed the patient presented to the hospital six times between 08/25/25 and 12/08/25. During an interview on 12/16/25 at 1:45 PM, Staff A confirmed that she identified bed bugs on Patient A in 08/2025, notified her supervisor and completed two related event reports. Staff A stated that she did not receive education on what to do when bed bugs were found, and was unaware the bed bug policy had been revised. During an interview on 12/16/25 at 1:58 PM, Staff B, Housekeeper, stated, “We don’t really have a bed bug issue ...I don’t think it’s a big issue if I see a bed bug or lice crawling on them (patients).” During an interview on 12/16/25 at 2:15 PM, Staff C, Director of PHN, stated that she was involved in the coordination, communication, and physical placement of Patient #1 in the outpatient clinic during scheduled clinic visits, and was aware that both Patient #1 and Patient #2 had bed bugs. Staff C stated that she saw Patient #2 recently in the hospital pharmacy area, waiting in a line of individuals for medication. Staff C confirmed that she did not watch an educational video related to bed bug control and was unsure if other PHN staff had watched the video. During an interview on 12/16/25 at 3:08 PM, Staff F, ED RN, stated that there have been increasing amounts of patients with bed bugs in the ED over the past three months. During an interview on 12/16/25 at 3:18 PM, Staff K, Outpatient Clinic RN, stated that she did not receive education or training related to controlling the spread bed bugs. During an interview on 12/16/25 at 3:25 PM, Staff G, Outpatient Clinic RN, stated she was not educated on what to do if a patient had bed bugs. During an interview on 12/16/25 at 3:35 PM Staff H, Outpatient Clinic Nurse Practitioner, stated that she did not receive training related to controlling the spread of bed bugs. Hospital staff identified and reported visible bed bugs to hospital leadership, and the hospital failed to initiate timely actions to prevent the spread of bed bugs within the hospital. Once education related to bed bug management was developed, it was not provided to all staff who cared for patients, including the staff who came into direct contact with the two patients who were identified to have visible bed bugs.”

“A Life Safety Code Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from 11/6/24 to 11/7/24. At this unannounced Complaint Survey, PHS Indian Hospital Crow/Northern Cheyenne was found not to be in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 485.623 (c) (1), Standard: Life safety from fire and the related National Fire Protection Association (NFPA) standard 101 - 2012 edition. PHS Indian Hospital Crow/Northern Cheyenne has a total of 24 certified beds. The main hospital is a two-story building built in 1996 of Type II (000) construction. The building is fully sprinklered and there is supervised smoke detection located in the corridors and spaces open to the corridor. The requirement at 42 CFR 485.623 (c) (1) was NOT MET as evidenced by the following standard-level deficiencies:”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 39022 Based on observation, staff interview, and record review, the facility did not maintain the fire alarm system in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.4 and 9.6 and NFPA 72 - 2010 edition. Findings include: 1. On 11/7/24 at 8:25am, observation in the Operating Room (OR) suite revealed nearly all the ceiling tiles had been removed from the dropped ceiling to allow for remediation of mold concerns. Smoke detectors for the fire alarm system were set at the height of the dropped ceiling. There was an approximate four foot interstitial space between the level of the dropped ceiling and the roof deck. Since the ceiling tiles were removed, activation of the fire alarm system could be delayed before smoke levels dropped low enough for smoke detectors to activate. This finding was confirmed by the Quality Manager, Billings Area Engineer, and Facilities Manager at the time of observation. 2. On 11/7/24 at 10:30am, interview with the Crow Service Unit Safety Officer revealed the facility had an Interim Life Safety Measures (ILSM) plan for a fire watch. Review of the “Fire Sprinkler ILSM” (no date) revealed the plan only addressed a fire watch due to the sprinkler system not being inspected since August 2023. The plan did not address potential delays in activation of the fire alarm system as related to the mold remediation work being done in the OR. These findings were confirmed by hospital staff at the times of discovery and reviewed with the CEO at the exit conference.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 39022 Based on observation, staff interview, and record review, the facility did not ensure the sprinkler system was properly maintained in accordance with NFPA 101 - 2012 Edition Sections 19.3.5, 9.7.5 through 9.7.8 and NFPA 25 - 2011 Edition. Findings include: 1. On 11/7/24 at 8:25am, observation in the Operating Room (OR) suite revealed nearly all the ceiling tiles had been removed from the dropped ceiling to allow for remediation of mold concerns. Sprinklers were set at the height of the dropped ceiling. There was an approximate four foot interstitial space between the level of the dropped ceiling and the roof deck. Since the ceiling tiles were removed, activation of the sprinkler system could be delayed before heat levels dropped low enough for sprinklers to activate. This finding was confirmed by the Quality Manager, Billings Area Engineer, and Facilities Manager at the time of observation. 2. On 11/7/24 at 10:30am, interview with the Crow Service Unit Safety Officer revealed the facility had an Interim Life Safety Measures (ILSM) plan for a fire watch. Review of the “Fire Sprinkler ILSM” (no date) revealed the plan only addressed a fire watch due to the sprinkler system not being inspected since August 2023. The plan did not address any of the potential delays in activation of the sprinkler system as related to the mold remediation work being done in the OR. These findings were confirmed by hospital staff at the times of discovery and reviewed with the CEO at the exit conference.”